Alternative names for endometrial cancer

Endometrial cancer is also referred to as cancer of the womb or uterine cancer (uterus is the Latin term for womb).

What is endometrial cancer?

Endometrial cancer is a type of cancer that originates from the glandular tissue that lines the uterus (endometrium: from ‘endo’ meaning inside and ‘metrium’ meaning uterus, in Greek). There are different types of cancer that can form in the uterus, but endometrial cancer is by far the most common one.

What causes endometrial cancer?

Endometrial cancer develops when healthy cells of the endometrium start growing and multiplying in an uncontrolled fashion. These abnormal cells accumulate and form a tumour (abnormal growth). They can invade neighbouring tissues as well as spread elsewhere in the body (metastasize).

Two different mechanisms are thought to be implicated in development of endometrial cancer:

1. Circulating female hormones (oestrogens) stimulate buildup of the endometrium; higher than normal levels of oestrogen can lead to excessive growth and, eventually, cancer. Many recognised risk factors for this kind of cancer are related to exposure of the body to oestrogens. These include:

• never having been pregnant
• obesity
• suffering from infrequent or no ovulation such as in polycystic ovary syndrome
• diabetes mellitus
• older age
• using hormone therapy, such as tamoxifen for breast cancer
• early onset of periods and late menopause taking HRT in the form of oestrogen without taking progesterone (a female hormone that protects the endometrium).
   

1. Cancers that appear to occur spontaneously without an association with oestrogens. These tend to behave more aggressively but, fortunately, only account for a small percentage of endometrial cancers. There are some rare genetic syndromes that increase the risk of endometrial cancer. These include Lynch II syndrome (hereditary non polyposis colorectal cancer) and Cowden’s syndrome.

Maintaining a healthy bodyweight, regular moderate exercise and use of the combined oral contraceptive pill (i.e. a contraceptive pill containing both oestrogen and progesterone) are thought to decrease the risk of developing endometrial cancer.

What are the signs and symptoms of endometrial cancer?

Signs and symptoms that are common, but not exclusive, to endometrial cancer are:

    • vaginal bleeding in post-menopausal women (most common)
    • new or very severe symptoms of heavy, long periods in women over 40
    • bleeding between normal periods
    • an abnormal vaginal discharge (thin or clear) in post-menopausal women
    • pelvic pain or pain during sexual intercourse.

It is important to note that around 5% of women will not show any symptoms.

How common is endometrial cancer?

Endometrial cancer is the most common gynaecological cancer and the fourth most common cancer in women in the UK with 9700 new cases every year (2016-2018). Most of these are diagnosed in women over 50 years and the incidence peaks for women in their 70s.

Is endometrial cancer inherited?

Most cases of endometrial cancer are not inherited. There are a small number of families that carry genes for a syndrome called hereditary non polyposis colorectal cancer. In these families a specific type of bowel cancer is much more common as well as endometrial cancer. Other familial syndromes (e.g. Cowden’s syndrome) exist but are much less common.

How is endometrial cancer diagnosed?

If a woman presents with symptoms that would suggest endometrial cancer, the doctor will usually obtain a medical history and then perform a physical examination (including a vaginal examination). Following that, more tests will be required, which may include:

• An ultrasound scan: this is usually internal (through the vagina) and uses sound waves to depict the lining of the uterus (endometrium) and indicate potential pathology. 
• Biopsy of the endometrium: this is usually a quick and relatively painless procedure. A small tissue sample is removed from inside the uterus. The sample is obtained by inserting a thin tube through the vagina and cervix (neck of the womb). The sample is then examined under the microscope to check for abnormal cancer cells. 
• Hysteroscopy: a fine telescope camera is used to obtain views of the inside of the uterus. This can be done with local or no anaesthetic. It is now common practice for biopsy of the endometrium to be carried out under direct visualisation with hysteroscopy. 
• Hysteroscopy and biopsy under general anaesthesia can be carried out if the biopsy results are unclear. If not enough sample can be taken for testing, or if the views during a hysteroscopy when the patient is awake are poor, a small procedure may be needed where a hysteroscopy with a slightly thicker camera and a scrape of the inside of the uterus are undertaken.

Whilst some GPs will offer hysteroscopy and biopsy, the vast majority are carried out by gynaecologists. If cancer is suspected, women should be referred to a specialist gynaecologist within two weeks of diagnosis.

If the diagnosis of endometrial cancer is confirmed, further tests will be needed to help determine the extent of the cancer (known as staging). These tests may include:

• computerised tomography (CT) scan or occasionally magnetic resonance imaging (MRI) of the chest, abdomen and pelvis 
• blood tests

The staging of the cancer is crucial to help doctors decide on appropriate treatment and give answers regarding the possible long-term outcome. It may not be possible to complete the staging process until after treatment has begun, which often involves surgery to remove the uterus. There are four stages of endometrial cancer. In stage I, cancer is found only in the uterus and in stage IV, which is the most advanced, cancer has spread beyond the pelvic area to other tissues.

How is endometrial cancer treated?

The decision regarding treatment is usually taken by a team of experts including oncologists (cancer doctors) and gynaecologists, and depends on the stage and characteristics of the cancer as well as the woman’s general health. Treatment options include:

Surgery – surgery is the main treatment for women with endometrial cancer. A procedure called hysterectomy and bilateral salpingo-oophorectomy is performed (removal of the uterus, the fallopian tubes and both ovaries). This usually involves an open operation but can sometimes be done through keyhole surgery (laparoscopy). At the same time, local lymph nodes may be removed to prevent the cancer from spreading.

Radiotherapy – treatment with radiation uses powerful X-ray-like energy to destroy cancer cells. Radiotherapy may also be used to try and lower the risk of future recurrence of the cancer. It can be an option for patients who are not well enough for surgical treatment. Most radiotherapy is delivered externally by a machine to the patient. Another form of radiotherapy involves placing a pellet inside the vagina to give radiation that is more localised to the affected area and minimises radiation exposure to healthy tissues.

Chemotherapy – in chemotherapy, medications that are toxic to cancer cells are used. One drug or a combination may be used and the treatment may be given orally (pills) or intravenously (through the veins). Chemotherapy is usually reserved for women with advanced endometrial cancer.

Hormone therapy – this is a treatment that alters hormone levels and can influence the growth of cancer cells that are sensitive to these hormones. It is also used for more advanced cases of endometrial cancer that has spread outside the uterus. Examples include progesterone, tamoxifen and gonadotrophin-releasing hormone agonists.

Are there any side-effects to the treatment?

After treatment women are unable to have children; however, most women diagnosed with endometrial cancer are beyond reproductive age. Women who are not already menopausal will experience the abrupt onset of menopausal symptoms such as hot flushes and night sweats because their ovaries have been removed.

Surgery – with any kind of surgery, risks are involved, such as bleeding, infection, reactions to anaesthetics and/or injury to internal organs such as the bladder and bowel, as well as developing clots in the legs or lungs.

Radiotherapy – this may cause short- and long-term side-effects such as fatigue, loss of appetite, diarrhoea, urinary complaints, loss of pubic hair, redness and dryness of the skin, vaginal scarring/narrowing and bowel obstruction. Reduced white cell count is a serious side-effect that can occur after large amounts of radiation to the pelvis, causing bone marrow problems.

Chemotherapy – the side-effects depend on the specific medication and may include: fatigue, temporary hair loss, nausea and vomiting, diarrhoea, reduced white blood cell count with increased risk of serious infections, menopausal symptoms, and numbness of fingers and toes.

Patients should discuss any concerns about their treatment options and any possible side-effects with their doctor or specialist.

What are the longer-term implications of endometrial cancer?

Women suffering with endometrial cancer usually present in the early stages of the disease and therefore have better prognosis as compared to other cancers of the female genital tract. The five-year survival rate can be as high as 96% in cases of early localised cancers.

It should also be noted that there are rare cases of stage I endometrial cancer in young women who have not completed childbearing. In such patients an attempt can be made to preserve fertility with medical management after careful counselling regarding the potential risks. Patients should discuss any concerns relating to fertility treatments with their doctor or specialist. Some have suggested ovarian preservation after hysterectomy in young women wishing to have children in the future through egg retrieval and surrogacy. See the article on female infertility for further information about fertility treatments.

In addition to the physical aspects of the disease, it is important to acknowledge that women suffering from endometrial cancer can face intense emotional stress. Support from friends and family is invaluable in helping women come to terms with their condition. Many women have also found patient groups and other cancer survivors a useful resource for advice and support.